Provider Demographics
NPI:1154928919
Name:DANNEMAN, FREDERICK CHARLES III
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:CHARLES
Last Name:DANNEMAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-4033
Mailing Address - Country:US
Mailing Address - Phone:801-400-2578
Mailing Address - Fax:
Practice Address - Street 1:2059 E 3900 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84124-1747
Practice Address - Country:US
Practice Address - Phone:801-268-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8182493-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional